Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Older adults are increasingly presenting to emergency departments (ED) with psychiatric emergencies amid limited inpatient psychiatric capacity, resulting in prolonged ED boarding. Our primary objective was to quantify ED boarding duration for older adults awaiting psychiatric hospitalization in community EDs. We examined whether longer boarding was associated with functional decline and physical restraint.

Methods: We conducted a retrospective cohort study of ED encounters among adults ≥ 65 years of age who received a behavioral health evaluation by emergency services program (ESP) clinicians (non-prescriptive behavioral health professionals) who determined psychiatric level of care in two community EDs. The study period was from January 2023–June 2024. The primary outcome was boarding duration. We measured boarding duration from initiation of a psychiatric bed search to ED departure or psychiatric clearance. Secondary outcomes were functional decline (new loss of physical function that impaired activities of daily living, identified from serial nursing documentation during the ED stay) and physical restraint episodes. 

Results: Of 334 behavioral health encounters (mean age 76 years ± 7.4 years), 180/334 (53.9%) boarded ≥ 24 hours. The median boarding duration for psychiatric hospitalization was 44 hours (interquartile range 24-70). Functional decline occurred in 42/334 (12.6%) and restraint episodes in 27/334 (8.1%), with both events occurring only among encounters boarding ≥ 24 hours. Patients with neurocognitive disorders (157/334, 47.0%) had higher rates of functional decline (difference 17.1%, 95% CI, 7.3-26.4; P < .001) and restraint episodes (difference 11.2%, 3.0-19.1; P < .001) compared to patients without neurocognitive disorders.

Conclusion: In this community ED cohort, older adults awaiting psychiatric hospitalization frequently experienced prolonged boarding, associated with higher rates of functional decline and physical restraint. Limitations include the retrospective design and reliance on nursing documentation to identify functional decline, with wide confidence intervals due to small event counts, limiting causal inference.